Abstract: At approximately 4:24 p.m. on April 19, 2000, Employee #1, who worked the third shift on the motor repair line at the Ford Motor Company, had been on the job for approximately 1 hour. A new model was being assembled, and since only four to five units were built each night, shifts were often only 4 hours long. Coworkers stated that nothing unusual was happening, and no work had been done since the beginning of the shift because the employees were chatting with each other and their supervisor. The coworkers were just beginning to go to their work stations when they noticed Employee #1, who was bent forward, begin to have breathing problems from an apparent asthma attack. Employees on the plant floor placed a call for help, which went to security. At approximately 4:29 p.m., a security guard and in-house nurse responded and the nurse provided treatment. Employee #1's inhaler was empty. Some of his coworkers tried to calm him down and he was given another employee's inhaler. At 4:35 p.m., the nurse tried to give Employee #1 oxygen via a nose piece and told the guard to call for an outside ambulance. The ambulance arrived at 4:39 p.m. and began treatment at 4:40 p.m. At approximately 4:52 p.m., Employee #1 left for the North Kansas City Hospital, but he did not arrive until 5:32 p.m. because the ambulance had to pull off the road to attend to him. Employee #1 died at 5:55 p.m. His death was the result of cardiopulmonary arrest; a history of asthma and hypertension; and elevated BUN (blood urea nitrogen), creatinine, and glucose levels that were indicated in his lab data. A complaint was received from a coworker in the same department, who reported the case and stated that Employee #1's asthma attack was caused by painting done by facility maintenance. An investigation was opened on April 27, 2000. Ford representatives had not reported Employee #1's death because they did not think it was work-related. After an investigation, it appeared that no accident occurred and that Employee #1's death was not related to his work or work environment.